Treatments and drugs

Changing your lifestyle can go a long way toward controlling high blood pressure. Your doctor may recommend you eat a healthy diet with less salt, exercise regularly, quit smoking and maintain a healthy weight. But sometimes lifestyle changes aren't enough.

In addition to diet and exercise, your doctor may recommend medication to lower your blood pressure.

Your blood pressure treatment goal depends on how healthy you are.

Blood pressure treatment goals*

*Although 120/80 mm Hg or lower is the ideal blood pressure goal, doctors are unsure if you need treatment (medications) to reach that level.

Less than150/90 mm Hg

If you're a healthy adult age 60 or older

Less than140/90 mm Hg

If you're a healthy adult younger than age 60

Less than140/90 mm Hg

If you have chronic kidney disease, diabetes or coronary artery disease or are at high risk of coronary artery disease

If you're age 60 or older, and use of medications produces lower systolic blood pressure (such as less than 140 mm Hg), your medications won't need to be changed unless they cause negative effects to your health or quality of life.

Also, people older than 60 commonly have isolated systolic hypertension — when diastolic pressure is normal but systolic pressure is high.

Medications to treat high blood pressure

Thiazide diuretics. Diuretics, sometimes called water pills, are medications that act on your kidneys to help your body eliminate sodium and water, reducing blood volume.

Thiazide diuretics are often the first, but not the only, choice in high blood pressure medications. Thiazide diuretics include hydrochlorothiazide (Microzide), chlorthalidone and others.

If you're not taking a diuretic and your blood pressure remains high, talk to your doctor about adding one or replacing a drug you currently take with a diuretic. Diuretics or calcium channel blockers may work better for black and older people than do angiotensin-converting enzyme (ACE) inhibitors alone. A common side effect of diuretics is increased urination.

Beta blockers. These medications reduce the workload on your heart and open your blood vessels, causing your heart to beat slower and with less force. Beta blockers include acebutolol (Sectral), atenolol (Tenormin) and others.

When prescribed alone, beta blockers don't work as well, especially in black and older people, but may be effective when combined with other blood pressure medications.

Angiotensin-converting enzyme (ACE) inhibitors. These medications — such as lisinopril (Zestril), benazepril (Lotensin), captopril (Capoten) and others — help relax blood vessels by blocking the formation of a natural chemical that narrows blood vessels. People with chronic kidney disease may benefit from having an ACE inhibitor as one of their medications.

Angiotensin II receptor blockers (ARBs). These medications help relax blood vessels by blocking the action, not the formation, of a natural chemical that narrows blood vessels. ARBs include candesartan (Atacand), losartan (Cozaar) and others. People with chronic kidney disease may benefit from having an ARB as one of their medications.

Calcium channel blockers. These medications — including amlodipine (Norvasc), diltiazem (Cardizem, Tiazac, others) and others — help relax the muscles of your blood vessels. Some slow your heart rate. Calcium channel blockers may work better for black and older people than do ACE inhibitors alone.

Grapefruit juice interacts with some calcium channel blockers, increasing blood levels of the medication and putting you at higher risk of side effects. Talk to your doctor or pharmacist if you're concerned about interactions.

Renin inhibitors. Aliskiren (Tekturna) slows down the production of renin, an enzyme produced by your kidneys that starts a chain of chemical steps that increases blood pressure.

Tekturna works by reducing the ability of renin to begin this process. Due to a risk of serious complications, including stroke, you shouldn't take aliskiren with ACE inhibitors or ARBs.

Additional medications sometimes used to treat high blood pressure

If you're having trouble reaching your blood pressure goal with combinations of the above medications, your doctor may prescribe:

Alpha-beta blockers. In addition to reducing nerve impulses to blood vessels, alpha-beta blockers slow the heartbeat to reduce the amount of blood that must be pumped through the vessels. Alpha-beta blockers include carvedilol (Coreg) and labetalol (Trandate).

Vasodilators. These medications, including hydralazine and minoxidil, work directly on the muscles in the walls of your arteries, preventing the muscles from tightening and your arteries from narrowing.

Aldosterone antagonists. Examples are spironolactone (Aldactone) and eplerenone (Inspra). These drugs block the effect of a natural chemical that can lead to salt and fluid retention, which can contribute to high blood pressure.

To reduce the number of daily medication doses you need, your doctor may prescribe a combination of low-dose medications rather than larger doses of one single drug. In fact, two or more blood pressure drugs often are more effective than one. Sometimes finding the most effective medication or combination of drugs is a matter of trial and error.

Eating a healthier diet with less salt (the Dietary Approaches to Stop Hypertension, or DASH, diet)

Exercising regularly

Quitting smoking

Limiting the amount of alcohol you drink

Maintaining a healthy weight or losing weight if you're overweight or obese

Resistant hypertension: When your blood pressure is difficult to control

If your blood pressure remains stubbornly high despite taking at least three different types of high blood pressure drugs, one of which usually should be a diuretic, you may have resistant hypertension. People who have controlled high blood pressure but are taking four different types of medications at the same time to achieve that control also are considered to have resistant hypertension. The possibility of a secondary cause of the high blood pressure generally should be reconsidered.

Having resistant hypertension doesn't mean your blood pressure will never get lower. In fact, if you and your doctor can identify what's behind your persistently high blood pressure, there's a good chance you can meet your goal with the help of treatment that's more effective.

Your doctor or hypertension specialist can evaluate whether the medications and doses you're taking for your high blood pressure are appropriate. You may have to fine-tune your medications to come up with the most effective combination and doses. Adding an aldosterone antagonist such as spironolactone (Aldactone) often leads to control of resistant hypertension. Some experimental therapies such as catheter-based radiofrequency ablation of renal sympathetic nerves (renal denervation) and electrical stimulation of carotid sinus baroreceptors are being studied.

In addition, you and your doctor can review medications you're taking for other conditions. Some medications, foods or supplements can worsen high blood pressure or prevent your high blood pressure medications from working effectively. Be open and honest with your doctor about all the medications or supplements you take.

If you don't take your high blood pressure medications exactly as directed, your blood pressure can pay the price. If you skip doses because you can't afford the medications, because you have side effects or because you simply forget to take your medications, talk to your doctor about solutions. Don't change your treatment without your doctor's guidance.

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James PA, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). The Journal of the American Medical Association. 2014;311:507.

Eckel RH, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology. 2014;63:2960.

Prevention and treatment of high blood pressure. American Heart Association. http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Prevention-Treatment-of-High-Blood-Pressure_UCM_002054_Article.jsp. Accessed April 8, 2015.

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